“USUAL, CUSTOMARY, AND REASONABLE (UCR)”- WHAT …



“USUAL, CUSTOMARY, AND REASONABLE (UCR)”- WHAT DOES IT MEAN?

Most patients are aware that dental insurance can be highly complex. In most cases, it is very difficult for patients to be completely knowledgeable of their overall insurance benefits. Unfortunately, this leads to confusion, frustration, and waste of time.

We are often asked by our patients, “Your fee for this is over what my insurance company calls ‘USUAL and CUSTOMARY.’ Does that mean you are overcharging me?” That is a good question and one we are happy to answer.

Insurance companies, on an individual basis, come up with “USUAL, CUSTOMARY, AND REASONABLE” fees for all dental procedures for a certain geographic region. When our state dental association asks these companies for data to see how the numbers are arrived at and which, if any, dentists were surveyed, they are told by your insurance company that this is confidential, internal information and they will not reveal it.

Our answer is, If this survey was done fairly and truly represents the fees in a given area, then why can’t we see how it was done? The insurance industry seems to be incapable of understanding this type of logic. The fact is that different insurance companies have “REASONABLE and CUSTOMARY” fees for the same area. If the calculations were done fairly, they should have the same fees within a geographic area.

The end result of insurance companies establishing artificially low “USUAL, CUSTOMARY, and REASONABLE” fees is animosity between the dentist and the patient. The insurance companies anticipate that the dentist will feel compelled to lower his/her fees to avoid conflict with the patient. The result is the insurance company benefits by paying out less money.

Dental insurance is provided through a contract between an employer and a dental insurance company. The coverage received is based on the terms that were negotiated between the two organizations. Dental offices have no involvement in determining which dental procedures are covered, the maximum benefit payable for each procedure, the percentage of the fee that is covered (and the resulting deductible you must pay), or if a specific procedure is reimbursed at all. These terms are simply a matter of a contract negotiated between the employer and the insurance company. Your employer buys a contract at a specified premium and includes as many or as few benefits that they negotiate. It is a well-known fact within the industry that higher premiums paid by the employer will get you, the patient, a higher “USUAL, CUSTOMARY and REASONABLE” fee schedule with more procedures covered.

Our fees are set based on the actual cost of doing business in our particular office. To avoid misunderstandings regarding your dental coverage benefits, please be aware that your actual benefits may or may not cover all charges incurred during your treatment. We collect an estimated amount at time of treatment based on the information your individual insurance carrier provided. Therefore you are totally responsible for all charges, including any difference remaining after payment by your insurance carrier. We encourage you to contact your dental carrier prior to your dental appointment to discuss your benefits in detail therefor there are no misunderstandings concerning your coverage after we submit your claim. If you do not feel that an insurance company made the correct payment on your behalf, you may appeal their determination. We will be happy to assist in the preparation of any additional information required by your insurance company for reconsideration of your entitled benefits.

(R-2020)

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